A nurse is reinforcing teaching with new parents about the provider's prescription for a serum bilirubin test. Which of the following statements should the nurse include in the explanation?

"Your baby is at a higher risk because they were born with congenital dermal melanocytosis.”

"This is because your baby is breastfed. You should start supplementing with formula."

"Your baby is at a higher risk because they have had four bowel movements in the first day of life.”

"This is because your baby's liver is not yet efficient at breaking down red blood cells."

Answer and Explanation

The Correct Answer is D

A. "Your baby is at a higher risk because they were born with congenital dermal melanocytosis.": Congenital dermal melanocytosis, also known as Mongolian spots, are harmless pigmented birthmarks and are unrelated to bilirubin levels or jaundice risk in newborns.

B. "This is because your baby is breastfed. You should start supplementing with formula.": Breastfeeding itself is not a reason to stop or supplement with formula unless medically necessary. Breastfeeding jaundice can occur, but proper feeding techniques and frequency usually manage it without needing supplementation.

C. "Your baby is at a higher risk because they have had four bowel movements in the first day of life.": Frequent bowel movements actually help lower bilirubin levels by aiding in the excretion of bilirubin through stool, so this would not increase jaundice risk.

D. "This is because your baby's liver is not yet efficient at breaking down red blood cells.": Newborns often experience physiological jaundice because their immature livers cannot efficiently process the breakdown products of red blood cells, leading to elevated bilirubin levels in the blood.

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Correct Answer is D

Explanation

A. "I will use a sitz bath at least once a day.": Sitz baths should be used more frequently, typically several times a day, to promote perineal healing, relieve discomfort, and reduce swelling after an episiotomy. Limiting it to once daily may not provide adequate relief or hygiene support.

B. "I will check the amount of bleeding with every other pad change": The amount of lochia (postpartum bleeding) should be checked with every pad change, not every other. Monitoring bleeding closely helps detect signs of hemorrhage or infection early, ensuring prompt intervention if abnormalities are found.

C. "I will wash my perineum with mild soap and warm water every other day.": Perineal hygiene should be performed daily, and often multiple times a day, especially after urination or bowel movements. Washing every other day is insufficient and could increase the risk of infection at the episiotomy site.

D. "I will change my pad at least three times a day": Changing the perineal pad at least three times daily, or more often as needed, maintains cleanliness, helps prevent infection, and allows for regular monitoring of lochia and healing. This statement demonstrates good understanding of postpartum perineal care.

A. Explain the rounding schedule to the client B. Tell the client about the visiting hours C. Review meal options with the client. D. Place the call light within reach of the client.

Correct Answer is D

Explanation

A. Explain the rounding schedule to the client: While explaining the rounding schedule helps reassure the client that frequent checks will occur, it does not immediately address safety needs. Immediate actions to reduce fall risk are prioritized before providing routine information.

B. Tell the client about the visiting hours: Informing the client about visiting hours is part of general orientation but is not critical to preventing falls. Safety interventions must be implemented first to minimize risk of injury as soon as possible upon admission.

C. Review meal options with the client: Discussing meal options is part of admission and planning for nutrition, but it is not an urgent action to ensure the client's immediate safety, particularly when there is a known risk for falls.

D. Place the call light within reach of the client: Ensuring the call light is within reach allows the client to easily request assistance before attempting to move independently. This simple action is a high-priority intervention to prevent falls and promote immediate client safety.

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A nurse is reinforcing teaching with new parents about the provider's prescription for a serum bilirubin test. Which of the following statements should the nurse include in the explanation?

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Naxlex Comprehensive Predictor Exams

A nurse on a postpartum unit is reinforcing discharge teaching for a client who had an episiotomy. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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